Making the Diagnosis: It’s All In The Clues

Doctors are not much different from detectives.  A “crime” has been committed (the health problem) and the “perpetrator” (diagnosis) is sought.

In both professions clues are used to solve the case.

When you go to the orthopedist you have a “chief complaint”: pain, weakness, numbness, instability etc, and you have a “clinical history”: a timeline and description of your problem.

First, the doctor will determine the clinical history of the problem by asking a series of specific questions.  After that, he or she will perform the physical examination.  The data obtained from these exercises are the clues he or she uses to arrive at a conclusion.  If at that point a diagnosis is not obvious, the orthopedist enlists tests that will provide additional clues: imaging, including x-rays, ultrasound, CT, MRI (looking for fractures, rotator cuff tears, ruptured discs, etc), blood tests (looking for rheumatoid arthritis, lyme disease, etc), nerve conduction studies (looking for neuropathies like carpal tunnel syndrome).   In addition, your swollen joint may be “tapped” and the fluid examined for gout, infection, or bleeding.

If the “perpetrator” still has not been found, diagnostic trials maybe utilized and your clinical response carefully noted.  These trials include physical therapy, splinting, and diagnostic injections.  Occasionally, when the diagnosis remains elusive, the orthopedist will recommend a second opinion.

Fortunately, many cases are straight forward. For example, the patient slips on the ice (clinical history), the wrist is deformed (physical exam), an x-ray (imaging) is ordered and the suspected wrist fracture (diagnosis) is confirmed.  However, contrast this with the elderly diabetic who presents with gradual onset of hip or back pain. In this case, the diagnosis is not clear cut and will require more complex investigation.

What can you do to help?  Give a clear and concise history.  Tell the doctor when the pain or disability started and what, if anything, precipitated it?  What activities or maneuvers aggravate and relieve it?  Characterize the pain, avoiding comments such as, “I can really take pain, doc, but this one is a killer”, in favor of the more helpful, “This pain is so severe it wakes me up at night and prevents me from returning to sleep”.

Your medical history is important:  do you smoke, drink alcohol excessively, have diabetes, cancer, or rheumatoid arthritis?  Have you had prior surgery, especially orthopedic procedures?   Do you take any medications, particularly prednisone, blood thinners, or anticancer drugs?

You, the patient, hold the key to the diagnosis.  The orthopedist cannot do this without your help. Be as objective as you can when detailing your history.  Consider keeping a journal. The mind is notorious for suppressing details surrounding painful events.

Remember, you are part of the investigating team.  With your help your doctor can solve the mystery, find the perpetrator and initiate treatment, all in a timely manner.